AUGUSTA — Following a national push by Democrats to bolster a linchpin of the federal health care law, the state Senate gave preliminary approval Monday to a bill that would expand Medicaid in Maine.

In a party-line vote after nearly four hours of passionate debate, the Senate voted 20-15 to advance L.D. 1546, a bill that ties Medicaid expansion with Gov. Paul LePage’s plan to pay off the state’s estimated $186 million share of debt to Maine’s 39 hospitals.

Sen. Richard Woodbury, an independent from Yarmouth, voted with the Democratic majority.

The bill, fiercely opposed by Republicans, is designed to combine one of the Democrats’ leading policy initiatives with a hospital payback that LePage has pushed since he campaigned for governor in 2010.

The hospital payback distinguishes Maine from other states where Democratic lawmakers have made Medicaid expansion a key front in the battle over the Affordable Care Act.

While some Republican governors have agreed to participate in Medicaid expansion, their colleagues in other states are resisting expanding the public insurance program for the poor, which now covers 17 percent of the 260 million Americans with health insurance.

So far, 21 states have agreed to participate in Medicaid expansion through the Affordable Care Act. Six states, including Maine, have not yet decided.

Maine Democrats are using their legislative majority to push an issue that could provide health insurance for an additional 60,000 low-income residents. Democratic leaders hope that tying Medicaid expansion to LePage’s popular hospital payback plan will persuade Republicans to back both initiatives.

Monday’s debate in the Senate showed that the effort is meeting unified Republican resistance. Republicans argued that increasing Medicaid requires more study, given Maine’s struggle with its MaineCare budget. MaineCare is the state’s Medicaid program.

Republicans tried to delay the vote. During the floor debate, Sen. Garrett Mason, R-Livermore Falls, said unanimous agreement to repay Maine’s hospitals had been tainted by tying it to a “massive welfare expansion.”

“We’re doubling-down on failed policies,” said Mason, arguing that Maine’s expansion of Medicaid in 2003 is responsible for the current hospital debt.

Mason said it is unrealistic to expect that the federal government will keep its promise to continue reimbursing states for 90 percent of the expansion after paying 100 percent of the cost from 2014 to 2016.

Democrats argued that the expansion would reduce hospital charity care while insuring more low-income Mainers. The measure is fiscally and morally right, they said.

“Too many Mainers are one accident or one illness away from financial ruin,” said Sen. Margaret Craven, D-Lewiston.

Democrats, some fighting back emotion, tried to put human faces on the benefits of increasing Medicaid eligibility by reading letters from recipients.

Sen. Troy Jackson, D-Allagash, talked about two friends in his district who died from heart failure after being diagnosed initially with acid reflux. Neither had health insurance.

Jackson had a similar diagnosis, but later found that he had a heart condition. He now has a pacemaker but carries the guilt of having health insurance because he’s a legislator.

“It’s … embarrassment that I had health insurance and they didn’t,” Jackson said. “It’s embarrassment that I’m alive and they didn’t have that opportunity.”

He said, “I know, of the three of us, I was the one who had health insurance. I don’t believe I’m on a different level or that I deserve health insurance.”

Democrats also rebutted claims that the program is “welfare.”

Sen. John Patrick, D-Rumford, said that “if welfare is providing health care for people living on the margins” and “scraping by with poverty wages,” he would support such a measure “every time.”

According to the Congressional Budget Office, the expansion would cover non-elderly adults earning as much as 133 percent of the federal poverty level, just over $20,500 a year for a two-person household. The CBO estimated that 49 percent of those affected by expanded Medicaid eligibility earn $5,745 a year or less.

The same study estimated that 37 percent of the people who would gain coverage would be 35 to 54 years old, and 11 percent would be 55 to 64.

Woodbury, the independent senator, said expanding Medicaid would help the state eliminate the “eligibility cliff,” meaning it would help people earning just above 133 percent of the poverty level by creating a new baseline for insurance subsidies available under the Affordable Care Act.

“That’s what makes (the health care law) work,” he said.

Also Monday, Cover Maine Now!, a coalition of 85 organizations, delivered nearly 3,000 signed petitions urging lawmakers to participate in the expansion.

“The Legislature and the governor have an opportunity right now to change lives, to help families be more secure, to stimulate our economy, to reduce insurance costs for business owners, to create jobs. And, most importantly, to save lives,” said Sara Gagn?olmes, executive director of Maine Equal Justice Partners, a progressive advocacy group for low-income residents. “There are few matters of public policy that can have such a dramatic effect on so many people.”

Roger Katz, R-Augusta, the assistant Republican leader in the Senate, said the combination effort could delay the hospitals’ repayment. He said there are too many unknown cost factors associated with Medicaid expansion.

“There may be good and compelling reasons on both sides (to expand Medicaid),” said Katz, and other members of his party are open to expansion. “We’re not ready to have that debate today.”

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